| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.57 | $2.57 | $79.43 |
Pharmacy-Other Pharmacy
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Medica
| Facility | $2.57 | $2.57 | $79.43 |